RHEUMATOID ARTHRITIS

Introduction:

 A chronic systemic inflammatory disorder

 Rheumatoid arthritis is a crippling disease
 Joint involvement is typically symmetric, affecting the wrist, metacarpal,
phalangeal, proximal, interphalangeal, elbow, shoulder, cervical spine,
hip, knee, and ankle joints.
 The distal interphalangeal joints are typically spared.
 Extra-articular manifestations include vasculitis, pericarditis, skin
nodules, pulmonary fibrosis, pneumonitis, and scleritis.
 The triad of arthritis, lymphadenopathy, and splenomegaly is known as
Felty's syndrome and is associated with anemia, thrombocytopenia, and
neutropenia.

Epidemiology

 Rheumatoid arthritis occurs two to four times more often in women than
men.
 The disease occurs in all age groups, but increases in incidence with
advancing age, with a peak between the fourth and sixth decades.
 Seventy-five percent of patients with rheumatoid arthritis carry
circulating rheumatoid factors, which are autoantibodies against portions
of the IgG antibody.
 Family studies indicate a genetic predisposition.
 Genetic risk factors do not fully account for the incidence of RA,
suggesting that environmental factors also play a role in the etiology of
the disease.
 Climate and urbanization have a major impact on the incidence and
severity of RA in groups of similar genetic background.

Etiology

 It has been suggested that RA might be a manifestation of the response to

an infectious agent in a genetically susceptible host.

Clinical manifestations
Onset

 Characteristically, RA is a chronic polyarthritis.

 Specific symptoms usually appear gradually as several joints, especially
those of the hands, wrists, knees, and feet, become affected in a
symmetric fashion.

Signs and Symptoms of Articular Disease

 Pain, swelling, and tenderness may initially be poorly localized to the

joints.
 Pain in affected joints, aggravated by movement, is the most common
manifestation of established RA.
 Generalized stiffness is frequent and is usually greatest after periods of
inactivity.
 Morning stiffness of greater than 1-h duration is an almost invariable
feature of inflammatory arthritis and may serve to distinguish it from
various noninflammatory joint disorders.
 The majority of patients will experience constitutional symptoms such as
weakness, easy fatigability, anorexia, and weight loss.
 Clinically, synovial inflammation causes swelling, tenderness, and
limitation of motion.
 Warmth is usually evident on examination, especially of large joints such
as the knee, but erythema is infrequent.
 Pain originates predominantly from the joint capsule, which is
abundantly supplied with pain fibers and is markedly sensitive to
stretching or distention.
 Although inflammation can affect any diarthrodial joint, RA most often
causes symmetric arthritis with characteristic involvement of certain
specific joints such as the proximal interphalangeal and
metacarpophalangeal joints.
 Pain and swelling behind the knee may be caused by extension of
inflamed synovium into the popliteal space (Baker's cyst).
 Characteristic changes of the hand include
1. Radial deviation at the wrist with ulnar deviation of the digits, often
with palmar subluxation of the proximal phalanges ("Z" deformity);
2. Hyperextension of the proximal interphalangeal joints, with
compensatory flexion of the distal interphalangeal joints (swan-neck
deformity);
 3. Flexion contracture of the proximal interphalangeal joints and
extension of the distal interphalangeal joints (boutonniere
deformity); and
4. Hyperextension of the first interphalangeal joint and flexion of the
first metacarpophalangeal joint with a consequent loss of thumb
mobility and pinch.
 Typical joint changes may also develop in the feet, including eversion at
the hindfoot (subtalar joint), plantar subluxation of the metatarsal heads,
widening of the forefoot, hallux valgus, and lateral deviation and dorsal
subluxation of the toes.

Extraarticular Manifestations

 Rheumatoid nodules
 Rheumatoid vasculitis,
 Pleuropulmonary manifestations: pleural disease, interstitial fibrosis,
pleuropulmonary nodules, pneumonitis, and arteritis.
 Pericarditis
 Neurologic manifestations: neuropathies of median, ulnar, radial
(interosseous branch), or anterior tibial nerves.
 Eye: episcleritis,
 Felty's syndrome consists of chronic RA, splenomegaly, neutropenia,
and, on occasion, anemia and thrombocytopenia.
 Osteoporosis

Diagnosis

 American Rheumatism Association criteria for diagnosing and

categorizing rheumatoid arthritis
 Classic rheumatoid arthritis: Presence of 7 of the following findings:
1) Morning stiffness,
2) Pain on motion of 1 joint
3) Swelling of 1 joint
4) Swelling of an additional joint
5) Symmetric swelling of joints
6) Presence of subcutaneous nodules
7) Presence of rheumatoid factor in the serum
8) Poor results in the mucin clot test of synovial fluid
9) Characteristic roentgenographic changes
 10) Characteristic histopathologic findings in the synovial fluid
11) Characteristic histopathologic findings in nodule biopsies.
 Definite rheumatoid arthritis: Presence of 5 of the above findings.
 Probable rheumatoid arthritis: Presence of 3 of the above findings.
 1-4 Findings must be present for at least 6 weeks.

Treatment

General Principles

 The goals of therapy of RA are

1. Relief of pain
2. Reduction of inflammation
3. Protection of articular structures
4. Maintenance of function
5. Control of systemic involvement
 A variety of physical therapy modalities may be useful in decreasing the
symptoms of RA.
 Rest ameliorates symptoms and can be an important component of the
total therapeutic program.
 In addition, splinting to reduce unwanted motion of inflamed joints may
be useful.
 Exercise directed at maintaining muscle strength and joint mobility
without exacerbating joint inflammation is also an important aspect of
the therapeutic regimen.
 A variety of orthotic and assistive devices can be helpful in supporting
and aligning deformed joints to reduce pain and improve function.

Medical management

 Medical management of RA involves five general approaches.

1. The first is the use of aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs) and simple analgesics to control the
symptoms and signs of the local inflammatory process.
2. The second line of therapy involves use of low-dose oral
glucocorticoids.
3. The third line of agents includes a variety of agents that have been
classified as the disease-modifying or slow-acting antirheumatic
 drugs. It includes methotrexate, gold compounds, D-penicillamine,
the antimalarials, and sulfasalazine
4. A fourth group of agents is the TNF-α neutralizing agents, which
have been shown to have a major impact on the signs and symptoms
of RA.
5. A fifth group of agents are the immunosuppressive and cytotoxic
drugs that have been shown to ameliorate the disease process in some
patients.

Surgery

 Surgery plays a role in the management of patients with severely

damaged joints.
 Although arthroplasties and total joint replacements can be done on a
number of joints, the most successful procedures are carried out on hips,
knees, and shoulders.
 Realistic goals of these procedures are relief of pain and reduction of
disability.